ProceedingS.Z.P.G.M.I vol: 5 (Hl91), pp. 11-13
High Undescended Testis a New Technique
for Orchidopexy
Khurram Ayub, Khalid Durrani and Mahmood Ahmad Chaudhry
Depa1tment of Surgery, Shaikh Zayed Postgraduate Medical Institute, Lahore
T
he term cryptorchidism meaning hidden testis
(Greek c1yptos: orchis) has now been widely
accepted as appropriate for the different forms of
undescended testis. This is the most common
disorder of sexual differentiation in the male. About
4% of the new born boys have an undescended testis.
At one monthh the incidence falls to 1.8% and by 9
months it is further diminished to about 0.8%1 In
1762 John Hunter concluded that the testicle was
directed in its descent by the Gabernaculum -- the
word meaning "Helm" or "Helms man" and if descent
was arrested he said, "it is not easy to ascertain the
cause of failure of the descent, but I am inclined to
suspect that fault originates in the testis
themselves. "2 This holds true even to this day and
age.
Whereas 3/4th of the undescended testis at
bilth will descend by the age of one year, for the
remaining 1/4th surgery is indicated preferably at
an early stage. The general agreement now is to
peiform orchidopexy between 18 mQnths to 2 years
of age 1 •3,
The object of treatment in cryptorchidism is to
place the testis into the scrotum, in order to improve
spermatogenesis, to make the testis more accessible
for examination for the detection of malignancy, to
correct the associated hernia and to alleviate the
psychological problems related to this disorder.
Although standard orchidopexy technique will
allow the testis to be brought down into the scrotum
in majo1ty of the cases, there are those, in which
adequate length of the spermatic vessels cannot be
achieved by this method "High undescended testis)".
This high undecended testis is encountered more
often in impalpable testis (about 20%) in which
mobilization of the testis into the scrotum without
risking its viability presents an operative challenge.
Several techniques have been decribed in the
past to deal with this difficult situation, ranging from
extensive mobilization of the spermatic vessels to
staged procedues and finally upto autotransplantion
of the testicle through micro vascular techniques.
We have devised a simple technique whereby re-
routing of the spermatic vessels behind the
transversalis fascia gives an additiona.l 3-4 cm of
length to the testicular pedicle, so that the testes can
be placed into the scrotum. This technique is a
modification of a previously described procedure
(Prentiss maneuver) involving the devision of the
inferior epigastric vessels and the transversalis fascia
to place the spermatic vessels medially4
MATERIAL AND METHOD
Over a period of four years (from 1987 to 1990),
A total No of 90 cases of undescended testis were
operated upon. This includes all patients under 14
years of age who were offered orchidopexy. About 40
% (36) of these cases had impalpable testis and 33%
(30) were considered to be high undescended testis
(Testis at or close to the deep inguinal ring in which
following adequate mobilization of the testicular
pedicle it was not possible to bring the testis into the
midscrotum. In these cases the new technique of
subfascial rerouting of the spermatic vessels were
carried out by the senior author (Mahmood Ahmad).
Steps of the operation
All steps of the operation are described briefly
for a better understanding and the ease of presen­
tation. Steps 1, 2, 3 and 5 are reproduced from the
standard texts 1 • •
3
Technique
Step-1.
A skin crease incision is made 1 cm above and
parallel to the medial two-third of the inguinal
ligament. Inguinal canal is opened by dividing
external oblique in the line of its fibres. A
careful search is made for the testis. Once found
the tunica of the testis is cleared of adheren�
tissues and the gubernaculum at the lov.·er Jde
divided. Cremasteric fascia is cleared from the
spermatic cord by blunt gauze dissection so :hz::
the cord lies free up to the interna1 ring. A..-.ery
forceps may be applied to the tu.n.ica
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Chaudhry et al.
Step-2
The covering of the cord is then divided
longitudinally and free margins held apart with
forceps so as to expose the contents. If a hernial
sac is found, an inguinal herniotomy is
performed. In the proximal pa1t of the cord the
vas deferens and testicular vessels are dissected
free from the surrounding tissue. The vas and
vessels are then held to one side and the
remaining tissue divided transversely.
Step-3
At this stage the testis is suspended from the
internal ring only by the vas and vessels. The
peritoneum is lifted free by blunt dissection
using a finger or gauze and the bands, lateral to
the spermatic vessels seen when the vessels are
under gentle traction, are divided.
Step-4
At this stage the testis can usually be placed
into scrotum, but when tension on the vessels is
expected, an a1te1y forceps is passed behind the
fascia transversalis from a point just above the
pubic tubercle, and is advanced laterally
towards the deep ring. A finger is kept over the
point where pulsation of extrnal iliac vessels is
felt, and the tip of the a1tery forceps brought
out of the deep ring. The testis is held by the
a1tery forceps applied to the tunica at the lower
pole. By withdrawing the forceps, the testis is
pulled behind the fascia tranversalis out of the
small hole above the pubic tubercle.
Step-5
The testis may be placed in a pouch in the
scrotal wall between the Da1tos and the skin
(Da1tos Pouch). First a finger is pushed
through the inguinal wound to break down
fascia occluding the neck of the scrotum and to
stretch the corrugated skin. With finger still in
place a transverse incision is made just through
the skin in the lower pa1t of the scrotum and a
pouch is developed between the da1tos and the
skin. An artery forceps is then pushed through
the dartos and the fascia, through the scrotum
and up-to the inguinal wound where the testis
is grasped, by the tunica. The testis is pulled
down through the da1tos into the pouch. The
scrotal skin is then closed over the testis with
absorbable interrupted sutures. The external
fixation stitch is some times required as an
additional measure to prevent retraction of the
testis.
RESULTS
Out of a total No 90 cases of undescended testis
29 patients underwent orchidopexy by the above
technique. In only one patient (age 14 years) the
testis could not be brought into the scrotum, and
hence orchiectomy was pe1formed. The post­
operative course and later follow up was satisfactory
in all those children who had orchidopexy by the
new technique (minimum 3 months).
DISCUSSION
C1yptorchidism is not an uncommon condition
and is frequently encountered in the general surgical
as well as paediatric practice. The high undescended
testis is a definite entity and poses a major problem
to the practising surgeon. In the present series of the
90 cases with c1yptorchdism, 30 were considered to
have high undescended testis (33%). This figure is
higher than 20% previously repo1ted in the
literature.3 The techniques previously described for
a difficult orchidopexy are given below.
(a)
Additional retroperitoneal dissection and
extensive mobilization of spermatic vessels to
gain extra length5 .
(b)
Fowler-Stephen's procedure, in which the
testicular a1te1y is devided in the hope that
testes will retain sufficient voscularity from
collateral blood flow through the a1try to Vas
(defrential a1te1y). The incidence of testicular
atrophy as with this procedure is about 30%
which is significent6 •
(c)
Staged Fowler-Stephens procedure:
The testicular a1te1y is simply ligated insitu to
allow the collateral blood supply to develop
without mobilizing the testes itself. 6-12
months later a standard Fowler-Stephen's
orchidopexy is carried out. 7
(d)
A planned two stage orchidopexy:
In the first stage the testis and the spermatic
cord after maximum mobilization are wrapped
with a silicone sheath to prevent adhesions and
12
Orchidopexy
placed in the inguinal canal. The second stage is
performed one year later. The success rate is
variable 70-80%.8
(e)
Testicular
autotransplantation,
through
microvascular technique:
A planned procedure and cannot be performed
before 2-4 years of age9 . This is a highly
specialized procedure and the experience is
limited.
REFERENCES
Elder JS. The undescended testis: Surg clinics of North
l.
Am 1988; 983- lOOG.
2.
3.
.J.
5.
(f)
Prentiss Maneuvour:
The inferior epigastric vessels are ligated and
the transversalis fascia in the floor of the
inguinal canal devided to allow the spermatic
vessels to be placed medially with a more direct
course to the scrotum.j .
(g) Rerouting of the testicular vessels (Authors
Technique):
Normally the testicular a1tery assumes a
trangular course from its origin at the aoita
through the deep inguinal ring down to the
base of the scrotum. Rerouting of the testicular
vessels behind the fascia transversalis makes
the course of these vessels direct, thus gaining
on extrra 3-4 cm length to the testicular pedicle
which is sufficient to bring the testes to the
scrotum without tension.
This technique is simpler one stage procedure
and obviates the need for the ligation, devision of the
fascia and vessels in the Floor of the inguinal canal
resulting in weakness of the posterior inguinal wall.
The technique was used in 30 cases of high
undescended testis and was successful in 29 (over
96% successful).
We conclude that our technique of sub fascial
re-routing of the spermatic vessels in orchidopexy
for the high undescended testis (the difficult type) is
simple safe and highly effective.
G.
7.
8.
9.
Gough MH. Cryptorchidism: Br J Surg 1989; 76: 109-112.
Rajfer J. Congenital anomalies of testis. In: Walsh PC,
Gittes RF, Perlmutter AD, Staamey, eds. Compbells
urology vol 2. 5th ed. Philadelphia: WB Saunders, 1986;
1917-G.J.
Prentiss RJ, Weickgenant CJ, et al. Undescended
Testis: Surgical anatomy of the spermatic vessels,
Spermatic Surgical Triangles, and lateral spermatic
ligament. J Urology 1983; 686: 19GO.
Jones PF, Bugley FH. Anabdominal Extraperitoneal
approach for difTerPnt orchidopexy. Br J Surg 1979; 66: 1418.
Fowler R, Stephen FD. the role of testicular vascular
anatomy in thP salvage of the high undescended Testes.
Aust NZJ Surg 1959; 29: 92.
Ransley PG. Vordermark JS, et al. Preliminary ligation
of the gonadal vessels prior to orchiope>.}' for the inlra­
abdominal trsticle: a staged Fowler-Stephens procedure.
World J Urol 1984; 2: 266.
Steinhardt GF, Kroovand RL, Perlmutter AD.
Orchiopex-y: planned 2-stage technique J Uol 1985; 133:
131.
Silber SJ. Microsurgery for the undescended testicle. Ural
Clin North Am 1985; 9: -130.
The Authors:
Khurram Ayub,
Medical Officer,
Drpartment ofSurgr ry,
Shaikh Zayed Postgraduatr Medical Institute,
Lahore.
Khalid Durrani,
Associate Professor,
Drpartment of Surgery,
Shaikh Zayed Postgraduatr Medical Institute,
Lahore.
Mahmood Ahmad Chaudhry,
Professor
Hrad of the Departmrnt of Surgery,
Shaikh Zayrd Postgraduate Medical Institute,
Lahore.
Address for Correpsondence:
Mahmood Ahmad Chaudh ry,
Profrssor
Head of the Department of Surgery,
Shaikh Zaycd Postgraduate Medical Institute,
Lahore.
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